No. 30180 (Repeal and Reenact): R501-2. Core Rules

DAR File No.: 30180
Filed: 07/11/2007, 09:45
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

Changes to this rule are necessary as a result of legislation passed in 2006 and 2007 that resulted in amendments to Title 62A, Chapter 2; need to clarify certain requirements that had previously been misinterpreted; need to insert clean-up language and additional details to aid with interpretations; need to create new sections to address basic health, safety and client care as required by Title 62A, Chapter 2.

Summary of the rule or change:

This rule makes a significant number of changes to the existing Rule R501-2, Core Rules, thus necessitating a "repeal and reenact". It facilitates substantive changes by establishing the following new sections, which did not previously exist in the repealed rule: Authority and Purpose; Definitions; Financial Requirements; Off-Site Activities; Medication and Medical Procedures; Infectious Disease; and Weapons. Although there are other substantive changes within this rule, many of the Program Administration, Governance, Record Keeping, Direct Service Management, Behavior Management, Rights of Clients, Personnel Administration, Emergency Plans, Safety, and Transportation requirements are basically the same as those found in the previous rule.

State statutory or constitutional authorization for this rule:

Section 62A-2-101 et seq.

Anticipated cost or savings to:

the state budget:

It is anticipated that there will be initial implementation costs associated to this rule in the way of development and printing of new checklists, training of staff, and some additional enforcement efforts. It is expected, however, that these costs can be absorbed in current budgets.

local governments:

There should be no direct costs to local governments because they do not operate programs that are regulated by this rule.

other persons:

There should be no cost to other persons except those listed below in "compliance costs for affected persons" and "comments by the department head".

Compliance costs for affected persons:

Human services Programs licensed under this rule will experience some administrative costs to modify or update policies and procedures manuals. Depending on the specific type of program some will experience mild to moderate cost increases in order to implement and adequately comply with the rule. There are those that will experience little or no cost increases.

Comments by the department head on the fiscal impact the rule may have on businesses:

The businesses that will be impacted fiscally by this rule are licensed to provide human service programs. Some of these businesses receive public funds through contract with the Department and will be evaluated for fiscal impact through the rate setting process. Private noncontracted human service programs may realize the need to set higher fees to offset any additional costs resulting from these regulations

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Human Services
Administration, Administrative Services, Licensing
120 N 200 W
SALT LAKE CITY UT 84103-1500

Direct questions regarding this rule to:

Ken Stettler at the above address, by phone at 801-538-4235, by FAX at 801-538-4553, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

08/31/2007

This rule may become effective on:

09/07/2007

Authorized by:

Ken Stettler, Director

RULE TEXT

R501. Human Services, Administration, Administrative Services, Licensing.

R501-2. Core Rules.

[R501-2-1. Definition.

Core Rules are required for Human Service Programs, listed in R501-2-14. Where there is duplication of review by another oversight agency, the Office of Licensing, shall accept that documentation as proof of compliance. Pursuant to 62A-2-106, the Office of Licensing will not enforce rules for licensees under contract to a Division in the Department of Human Services in the following areas:

A. the administration and maintenance of client and service records;

B. staff qualifications; and

C. staff to client ratios.

 

R501-2-2. Program Administration.

A. The program shall have a written statement of purpose to include the following:

1. program philosophy,

2. description of long and short term goals, this does not apply to social detoxification or child placing adoption agencies,

3. description of the services provided,

4. the population to be served,

5. fee policy,

6. participation of consumers in activities unrelated to treatment plans, and

7. program policies and procedures which shall be submitted prior to issuance of an initial licensing.

B. Copies of the above statements shall be available at all times to the Office of Licensing upon request. General program information shall be available to the public.

C. The program shall have a written quality assurance plan. Implementation of the plan shall be documented.

D. The program shall have clearly stated guidelines and appropriate administrative procedures, to include the following:

1. program management,

2. maintenance of complete, accurate and accessible records, and

3. record retention.

E. The governing body, program operators, management, employees, consultants, volunteers, and interns shall read, understand, follow and sign a copy of the current Department of Human Services Provider Code of Conduct.

F. The program shall comply with State and Federal laws regarding abuse reporting in accordance with 62A-4a-403 and 62A-3-302, and shall post copies of these laws in a conspicuous place within the facility.

G. All programs which serve minors or vulnerable adults shall submit identifying information for background screening of all adult persons associated with the licensee and board members who have access to children and vulnerable adults in accordance with R501-14 and R501-18.

H. The program shall comply with all applicable National Interstate Compact Laws.

I. A licensed substance abuse treatment program shall complete the National Survey of Substance Abuse Treatment annually. Substance abuse treatment programs shall also comply with Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2.

J. The program's license shall be posted where it is easily read by consumers, staff and visitors. See also R501-1-5-F. The program shall post Civil Rights License on Notice of Agency Action, abuse and neglect reporting and other notices as applicable.

K. The program shall not handle the major personal business affairs of a consumer, without request in writing by the consumer and legal representative.

L. Programs providing foster or proctor care services shall adhere to the following:

1. approve homes that comply with Foster Care Rules, R501-12. The agency shall be required to recruit, train, and supervise foster parents as defined by R501-12.

2. foster families meeting requirements shall be approved or certified by the agency. The agency must maintain written records of annual home approval. The approval process shall include a home study evaluation and training plan.

3. the agency must have a procedure to revoke or deny home approval.

4. the agency must have a written agreement with the foster parents which includes the expectations and responsibilities of the agency, staff, foster parents, the services to be provided, the financial arrangements for children placed in the home, the authority foster parents can exercise on children placed in the home, actions which require staff authorization.

5. planning, with participation of the child's legal guardian for care and services to meet the child's individual needs.

6. obtaining, coordinating and supervising any needed medical, remedial, or other specialized services or resources with the ongoing participation of the foster parents.

7. providing ongoing supervision of foster parents to ensure the quality of the care they provide.

 

R501-2-3. Governance.

A. The program shall have a governing body which is responsible for and has authority over the policies, training and monitoring of staff and consumer activities for all phases of the program. The governing body's responsibilities shall include the following:

1. to ensure program policy and procedures compliance,

2. to ensure continual compliance with relevant local, state and federal requirements,

3. to notify the Office of Licensing within 30 days of changes in program administration and purpose,

4. to ensure that the program is fiscally and operationally sound, by providing documentation by a financial professional that the program is a "going concern",

5. to ensure that the program has adequate staffing as identified on the organizational chart,

6. to ensure that the program has general liability insurance, professional liability insurance as appropriate, vehicle insurance for transport of consumers, and fire insurance, and

7. for programs serving youth, the program director or designee shall meet with the Superintendent or designee of the local school district at the time of initial licensure, and then again each year as the programs renews it's license to complete the necessary student forms including youth education forms.

B. The governing body shall be one of the following:

1. a Board of Directors in a non-profit organization; or

2. commissioners or appointed officials of a governmental unit; or

3. Board of Directors or individual owner or owners of a for-profit organization.

C. The program shall have a list of members of the governing body, indicating name, address and term of membership.

D. The program shall have an organization chart which identifies operating units of the program and their inter-relationships. The chart shall define lines of authority and responsibility for all program staff and identifies by name the staff person who fills each position on the chart.

E. When the governing body is composed of more than one person, the governing body shall establish written by-laws, and shall hold formal meetings at least twice a year, Child Placing Agencies must meet at least quarterly, maintain written minutes, which shall be available for review by the Office of Licensing, to include the following:

1. attendance,

2. date,

3. agenda items, and

4. actions.

 

R501-2-4. Statutory Authority.

A. A publicly operated program shall document the statutory basis for existence.

B. A privately operated program shall document its ownership and incorporation.

 

R501-2-5. Record Keeping.

The program shall have, a written record for each consumer to include the following:

A. Demographic information to include Medicaid number as required,

B. Biographical information,

C. Pertinent background information, including the following;

1. personal history, including social, emotional, psychological and physical development,

2. legal status,

3. emergency contact with name, address and telephone number, and

4. photo as needed.

D. Health records of a consumer including the following:

1. immunizations, for children only,

2. medication,

3. physical examinations, dental, and visual examinations, and

4. other pertinent health records and information.

E. Signed consent forms for treatment and signed Release of Information form,

F. Copy of consumer's individual treatment or service plan,

G. A summary of family visits and contacts, and

H. A summary of attendance and absences.

 

R501-2-6. Direct Service Management.

A. Direct service management, as described herein, is not applicable to social detoxification. The program shall have on file for public inspection a written eligibility policy and procedure, approved by a licensed clinical professional to include the following:

1. legal status,

2. age and sex of consumer,

3. consumer needs or problems best addressed by program,

4. program limitations, and

5. appropriate placement.

B. The program shall have a written admission policy and procedure to include the following:

1. appropriate intake process,

2. age groupings as approved by the Office of Licensing,

3. pre-placement requirements,

4. self-admission,

5. notification of legally responsible person, and

6. reason for refusal of admission, to include a written, signed statement.

C. Intake evaluation.

1. At the time of intake an assessment shall be conducted to evaluate health and family history, medical, social, psychological and, as appropriate, developmental, vocational and educational factors.

2. In emergency situations which necessitate immediate placement, the intake evaluation shall be completed within seven days of admission.

3. All methods used in evaluating a consumer shall consider age, cultural background, dominant language, and mode of communication.

D. A written agreement, developed with the consumer, and the legally responsible person if applicable, shall be completed, signed by all parties, and kept in the consumer's record, with copies available to involved persons. It shall include the following:

1. rules of program,

2. consumer and family expectations,

3. services to be provided and cost of service,

4. authorization to serve and to obtain emergency care for consumer,

5. arrangements regarding absenteeism, visits, vacation, mail, gifts, and telephone calls, when appropriate, and

6. sanctions and consequences.

E. Consumer treatment plan shall be individualized, as applicable according to the following.

1. A staff member shall be assigned to each consumer having responsibility and authority for development, implementation, and review of the plan.

2. The plan shall include the following:

a. findings of intake evaluation and assessment,

b. measurable long and short term goals and objectives,

1) goals or objectives clearly derived from assessment information,

2) goals or objectives stated in terms of specific observable changes in behavior, skills, attitudes or circumstances,

3) evidence that consumer input was integrated where appropriate in identifying goals and objectives, and

4) evidence of family involvement in treatment plan, unless clinically contraindicated,

c. specification of daily activities, services, and treatment, and

d. methods for evaluation,

3. Treatment plans

a. plans shall be developed within 30 days of consumer's admission by a treatment team and reviewed by a clinical professional if applicable. Thereafter treatment plans shall be reviewed by the licensed clinical professional if applicable as often as stated in the treatment plan.

4. All persons working directly with the consumer shall be appropriately informed of the individual treatment plan.

5. Reports on the progress of the consumer shall be available to the applicable Division, the consumer, or the legally responsible person.

6. Treatment record entries shall include the following:

a. identification of program,

b. date and duration of services provided,

c. description of service provided,

d. a description of consumer progress or lack of progress in the achievement of treatment goals or objectives as often as stated in the treatment plan, and

e. documentation of review of consumer's record to include the following:

1) signature,

2) title,

3) date, and

4) reason for review.

7. Transfer and Discharge

a. a discharge plan shall identify resources available to consumer.

b. the plan shall be written so it can be understood by the consumer or legally responsible party.

c. whenever possible the plan shall be developed with consumers participation, or legally responsible party if necessary. The plan shall include the following:

1) reason for discharge or transfer,

2) adequate discharge plan, including aftercare planning,

3) summary of services provided,

4) evaluation of achievement of treatment goals or objectives,

5) signature and title of staff preparing summary, and

6) date of discharge or transfer.

d. The program shall have a written policy concerning unplanned discharge.

8. Incident or Crisis Intervention records

a. The program shall have written policies and procedures which includes: reporting to program manager, documentation, and management review of incidents such as deaths of consumers, serious injuries, fights, or physical confrontations, situations requiring the use of passive physical restraints, suspected incidents of abuse or neglect, unusual incidents, strip searches and other situations or circumstances affecting the health, safety, or well-being of consumers.

b. records shall include the following:

1) summary information,

2) date, time of emergency intervention,

3) action taken,

4) employees and management responsible and involved,

5) follow up information,

6) list of referrals,

7) signature and title of staff preparing report, and

8) records shall be signed by management staff.

c. the report shall be maintained in individual consumer records.

d. when an incident involves abuse, neglect, serious illness, violations of the Provider Code of Conduct or death of a consumer, a program shall:

1) notify the Office of Licensing, legally responsible person and any applicable agency which may include law enforcement.

2) a preliminary written report shall be submitted to the Office of Licensing within 24 hours of the incident.

 

R501-2-7. Behavior Management.

A. The program shall have on file for public inspection, a written policy and procedure for the methods of behavior management. These shall include the following:

1. definition of appropriate and inappropriate behaviors of consumers,

2. acceptable staff responses to inappropriate behaviors, and

3. consequences.

B. The policy shall be provided to all staff, and staff shall receive training relative to behavior management at least annually.

C. No management person shall authorize or use, and no staff member shall use, any method designed to humiliate or frighten a consumer.

D. No management person shall authorize or use, and no staff member shall use nor permit the use of physical restraint with the exception of passive physical restraint. Passive physical restraint shall be used only as a temporary means of physical containment to protect the consumer, other persons, or property from harm. Passive physical restraint shall not be associated with punishment in any way.

E. Staff involved in an emergency safety intervention that results in an injury to a resident or staff must meet with the clinical professional to evaluate the circumstances that caused the injury and develop a plan to prevent future injuries.

F. Programs using time out or seclusion methods shall comply with the following:

1. The program will have a written policy and procedure which has been approved by the Office of Licensing to include:

a. Time-out or seclusion is only used when a child's behavior is disruptive to the child's ability to learn to participate appropriately, or to function appropriately with other children or the activity. It shall not be used for punishment or as a substitute for other developmentally appropriate positive methods of behavior management.

b. Time-out or seclusion shall be documented in detail and provide a clear understanding of the incident which resulted in the child being placed in that time-out or seclusion.

c. If a child is placed in time out or seclusion more than twice in any twenty-four hour period, a review is conducted by the clinical professional to determine the suitability of the child remaining in the program.

d. Any one time-out or seclusion shall not exceed 4 hours in duration.

e. Staff is required to maintain a visual contact with a child in time-out or seclusion at all times.

f. If there is any type of emergency such as a fire alarm, or evacuation notification, children in time-out or seclusion shall follow the safety plan.

g. A child placed in time-out or seclusion shall not be in possession of belts, matches, weapons, or any other potentially harmful objects or materials that could present a risk or harm to the child.

2. Time-out or seclusion areas shall comply with the following:

a. Time-out or seclusion rooms shall not have locking capability.

b. Time-out or seclusion rooms shall not be located in closets, bathrooms, or unfurnished basements, attic's or locked boxes.

c. A time-out or seclusion room is not a bedroom, and temporary beds, or mattresses in these areas are not allowed. Time-out and seclusion shall not preclude a child's need for sleep, or normal scheduled sleep period.

d. All time-out or seclusion rooms shall measure at least 75 square feet with a ceiling height of at least 7 feet. They shall have either natural or mechanical ventilation and be equipped with a break resistant window, mirror or camera that allows for full observation of the room. Seclusion rooms shall have no hardware, equipment, or furnishings that obstruct observation of the child, or that present a physical hazard or a suicide risk. Rooms used for time out or seclusion shall be inspected and approved by the local fire department

G. The program's licensed clinical professional shall be responsible for supervision of the behavior management procedure.

 

R501-2-8. Rights of Consumers.

A. The program shall have a written policy for consumer rights to include the following:

1. privacy of information and privacy for both current and closed records,

2. reasons for involuntary termination and criteria for re-admission to the program,

3. freedom from potential harm or acts of violence to consumer or others,

4. consumer responsibilities, including household tasks, privileges, and rules of conduct,

5. service fees and other costs,

6. grievance and complaint procedures,

7. freedom from discrimination,

8. the right to be treated with dignity,

9. the right to communicate by telephone or in writing with family, attorney, physician, clergyman, and counselor or case manager except when contraindicated by the licensed clinical professional,

10. a list of people, whose visitation rights have been restricted through the courts,

11. the right to send and receive mail providing that security and general health and safety requirements are met,

12. defined smoking policy in accordance with the Utah Clean Air Act, and

13. statement of maximum sanctions and consequences, reviewed and approved by the Office of Licensing.

B. The consumer shall be informed of this policy to his or her understanding verbally and in writing. A signed copy shall be maintained in the consumer record.

 

R501-2-9. Personnel Administration.

A. The program shall have written personnel policies and procedures to include the following:

1. employee grievances,

2. lines of authority,

3. orientation and on-going training,

4. performance appraisals,

5. rules of conduct, and

6. sexual and personal harassment.

B. The program shall have a director, appointed by the governing body, who shall be responsible for management of the program and facility. The director or designated management person shall be available at all times during operation of program.

C. The program shall have a personnel file for each employee to include the following:

1. application for employment,

2. applicable credentials and certifications,

3. initial medical history if directed by the governing body,

4. tuberculin test if directed by the governing body,

5. food handler permit, where required by local health authority,

6. training record,

7. annual performance evaluations,

8. I-9 Form completed as applicable,

9. comply with the provisions of R501-14 and R501-18 for background screening, and

10. a signed copy of the current Department of Human Services Provider Code of Conduct.

D. The program shall follow a written staff to consumer ratio, which shall meet specific consumer and program needs. The staff to consumer ratio shall meet or exceed the requirements set forth in the applicable categorical rules as found in R501-3, R501-7, R501-8, R501-11, and R501-16.

E. The program shall employ or contract with trained or qualified staff to perform the following functions:

1. administrative,

2. fiscal,

3. clerical,

4. housekeeping, maintenance, and food service,

5. direct consumer service, and

6. supervisory.

F. The program shall have a written job description for each position, which includes a specific statement of duties and responsibilities and the minimum level of education, training and work experience required.

G. Treatment shall be provided or supervised by professional staff, whose qualifications are determined or approved by the governing body, in accordance with State law.

H. The governing body shall ensure that all staff are certified and licensed as legally required.

I. The program shall have access to a medical clinic or a physician licensed to practice medicine in the State of Utah.

J. The program shall provide interpreters for consumers; or refer consumers to appropriate resources as necessary to communicate with consumers whose primary language is not English.

K. The program shall retain the personnel file of an employee after termination of employment, in accordance with accepted personnel practices.

L. A program using volunteers, substitutes, or student interns, shall have a written plan to include the following:

1. direct supervision by a program staff,

2. orientation and training in the philosophy of the program, the needs of consumers, and methods of meeting those needs,

3. background screening,

4. a record maintained with demographic information, and

5. signed copy of the current Department of Human Services Provider Code of Conduct.

M. Staff Training

1. Staff members shall be trained in all policies of the program, including the following:

a. orientation in philosophy, objectives, and services,

b. emergency procedures,

c. behavior management,

d. current program policy and procedures, and

e. other relevant subjects.

2. Staff shall have completed and remain current in a certified first aid and CPR, such as or comparable to American Red Cross.

3. Staff shall have current food handlers permit as required by local health authority.

4. Training shall be documented and maintained on-site.

 

R501-2-10. Infectious Disease.

The program shall have policies and procedures designed to prevent or control infectious and communicable diseases in the facility in accordance with local, state and federal health standards.

 

R501-2-11. Emergency Plans.

A. The program shall have a written plan of action for disaster and casualties to include the following:

1. designation of authority and staff assignments,

2. plan for evacuation,

3. transportation and relocation of consumers when necessary, and

4. supervision of consumers after evacuation or relocation.

B. The program shall educate consumers on how to respond to fire warnings and other instructions for life safety including evacuation.

C. The program shall have a written plan which personnel follow in medical emergencies and arrangements for medical care, including notification of consumer's physician and nearest relative or guardian.

 

R501-2-12. Safety.

A. Fire drills in non-outpatient programs, shall be conducted at least quarterly and documented. Notation of inadequate response shall be documented.

B. The program shall provide access to an operable 24-hour telephone service. Telephone numbers for emergency assistance, i.e., 911 and poison control, shall be posted.

C. The program shall have an adequately supplied first aid kit in the facility such as recommended by American Red Cross.

D. All persons associated with the program who have access to children or vulnerable adults and who also have firearms or ammunition shall assure that they are inaccessible to consumers at all times. Firearms and ammunition that are stored together shall be kept securely locked in security vaults or locked cases, not in glass fronted display cases. Firearms that are stored in display cases shall be rendered inoperable with trigger locks, bolts removed, or other disabling methods. Ammunition for those firearms shall be kept securely locked in a separate location. This does not restrict constitution or statutory rights regarding concealed weapons permits, pursuant to UCA 53-5-701 et seq.

 

R501-2-13. Transportation.

A. The program shall have written policy and procedures for transporting consumers.

B. In each program or staff vehicle, used to transport consumers, there shall be emergency information which includes at a minimum, the name, address and phone number of the program and an emergency telephone number.

C. The program shall have means, or make arrangement for, transportation in case of emergency.

D. Drivers of vehicles shall have a valid drivers license and follow safety requirements of the State.

E. Each vehicle shall be equipped with an adequately supplied first aid kit such as recommended by American Red Cross.

 

R501-2-14. Categorical Rules.

In addition to Core Rules, Categorical Rules are specific regulations which must be met for the following:

A. Child Placing Adoption Agencies R501-7,

B. Day Treatment R501-20,

C. Intermediate Secure Treatment Programs for Minors R501-16,

D. Outdoor Youth Programs R501-8,

E. Outpatient Treatment R501-21,

F. Foster Care R501-12,

G. Residential Treatment R501-19,

H. Residential Support R501-22,

I. Social Detoxification R501-11 and

J. Assisted Living for DSPD Residential R710.

 

R501-2-15. Single Service Program Rules.

Core Rules of the Office of Licensing do not apply to single service programs.

Single services program Rules are the regulations which must be met for the following:

A. Adult Day Care, which Rules are found in R501-13,

B. Adult Foster Care, which Rules are found in R501-17.]

R501-2-1. Authority and Purpose.

This Rule is authorized by Section 62A-2-106, et seq.

This Rule describes the basic health and safety standards all human services programs, with the exception of foster homes for children, are required to comply with.

This Rule describes the minimum administration and financial requirements all human services programs, with the exception of foster homes for children, are required to comply with.

 

R501-2-2. Definitions.

(1)(a) "Abuse" includes, but is not limited to:

(i) actual, attempted, or threatened non-accidental harm, to the physical, psychological, or emotional health of a client;

(ii) the use of confinement, physical restraint, medication, or isolation that causes or may cause harm to a client;

(iii) the deprivation of treatment, food, or hydration, except as provided by law;

(iv) causing physical injury or pain, including but not limited to bleeding, bruising, swelling, dislocation, contusion, laceration, burning, bone fracture, bodily damage, or death;

(v) corporal punishment, including but not limited to hitting or slapping;

(vi) domestic-violence-related abuse;

(vii) sexual abuse or sexual exploitation; or

(viii) "severe emotional abuse", "severe physical abuse", or "emotional or psychological abuse", as these terms are defined in sections 62A-4a-101 and 62A-3-301.

(b) Abuse does not include:

(i) reasonable discipline of a client in accordance with the licensee's policy and procedure manual that has been approved by the Office of Licensing;

(ii) withholding a client's privileges; or

(iii) the use of reasonable and necessary physical restraint or force in self-defense, in defense of others, or to protect the client.

(2) "Adult" means an individual who is 18 years of age, or older.

(3) "Adult day care" is defined in Section 62A-2-101.

(4) "Background screening clearance" means written verification that the Office of Licensing has approved an applicant's criminal, abuse, neglect, and exploitation background screenings.

(5) "Behavior Consultant" is a professional certified by The Division of Services for People with Disabilities to assess and develop educational procedures and techniques.

(6) "Bodily fluids" includes but is not limited to blood, saliva, feces, urine, nasal discharge, or vomit, but does not include tears or perspiration.

(7) "Chemical restraint" means any drug or substance used to control a client's behavior or movement that is not prescribed and monitored by the client's personal physician.

(8) "Child" is defined in Section 62A-2-101.

(9) "Child placing" is defined in Section 62A-2-101.

(10) "Client" is defined in Section 62A-2-101.

(11) "Communicable disease" is defined in Section 26-6-2.

(12) "Competency and proficiency requirements" are the essential skills and abilities that must be demonstrated by staff, as assessed in a written performance evaluation by the staff's supervisor.

(13) "Day treatment" is defined in Section 62A-2-101.

(14) "Dangerous weapon" includes but is not limited to "firearms", "antique firearms", "explosive, chemical, or incendiary devices", ammunition, and other items as defined in Sections 76-10-306 and 76-10-501.

(15) "Direct access" is defined in Section 62A-2-101.

(16) "Direct care staff" means an individual who provides educational, vocational, therapeutic, or treatment services; supervision of a client; or care directly to a client; and does not include support staff.

(17) "Directly supervised" is defined in Section 62A-2-120.

(18) "Domestic-violence-related abuse" means:

(a) domestic violence; or

(b) a violent physical or verbal interaction between cohabitants in the physical presence of a child or vulnerable adult, having knowledge that a child or vulnerable adult is present and may see or hear an act of domestic violence.

(19) "Domestic violence" is as defined in Section 77-36-1.

(20) "Emotional abuse" is as defined in Section 62A-3-301 and includes but is not limited to conduct that subjects the client to psychologically destructive behavior, such as making demeaning comments, threatening harm, terrorizing the client or alienating the client.

(21) "DSPD" means the Division of Services for People with Disabilities.

(22) "Exploitation" includes but is not limited to: using a client's property without the client's consent; using a client's property in a way that is contrary to the client's best interests, such as expending a client's funds for the benefit of another; making unjust or improper use of clients or their resources; accepting a gift in exchange for preferential treatment of a client; accepting a gift in exchange for services that the program is already obliged to provide to the client; using the labor of a client for personal gain; using the labor of a client without paying the client a legal wage or equivalent non-monetary compensation, except as in accordance with approved therapeutic practices and as approved by the Office of Licensing, U.S. Department of Labor, and the Department of Commerce. "Exploitation" does not include reasonable chores or community service work for a non-profit organization.

(23) "Financial Professional" is a person who has a college degree in accounting or a related field and is currently employed as an accountant or financial auditor that is actively engaged in financial accountability on a day-to-day basis.

(24) "Foster home" is defined in Section 62A-2-101.

(25) "Guardian" means a client's legal guardian or custodian, who is legally entitled to make placement, medical, and treatment decisions on behalf of the client.

(26) "Human services program" is defined in Section 62A-2-101.

(27) "Incident report" means a written description of any notable event, including but not limited to any crime, injury or illness, or unauthorized absence, and how that event was addressed.

(28) "Licensee" means a person with a current, valid license to operate a human services program, issued by the Office of Licensing.

(29) "Maltreatment" includes but is not limited to actual, attempted, or threatened:

(a) physical activity that is not consistent with the client's service plan, health and abilities;

(b) physical activity that is not consistent with standard therapeutic practices;

(c) restraint or seclusion used for the provider's convenience or to coerce, discipline or retaliate against a client;

(i) maltreatment does not include the lawful use of restraint or seclusion in emergency situations to protect any person when: a less restrictive intervention would be ineffective, the use is consistent with standard therapeutic practices, the use is administered by trained authorized personnel, and the use is terminated as soon as the emergency is controlled;

(d) group punishments for the misbehavior of individuals;

(e) disrespecting, bullying, teasing, provoking, intimidating, or agitating a client;

(f) denying a therapeutic, health or safety related program service to coerce, discipline or retaliate against a client;

(g) denial of visitation or communication privileges with the client's family, significant others, attorney, clergy, physician, or Office of Licensing;

(h) requiring a client to remain silent for periods of time to coerce, punish or retaliate against a client;

(i) unreasonable withholding of emotional response or stimulation;

(j) denying a current client from entering the client's residence for any purpose unrelated

to safety.

(30) "Mechanical restraint" means any device used to control or restrict a client's free movement, including but not limited to a locked door that the client cannot open, a locked window that the client cannot open, handcuffs, belts, straps, ties, or restraint jackets.

(31) "Medical emergency" means any medical condition that may be life threatening or require immediate medical assistance from a medical practitioner, including but not limited to unconsciousness, convulsions, severe bleeding, or severe pain.

(32) "Medical practitioner" means an individual licensed by the State of Utah under Utah Code Ann. Title 58 as a physician, physician's assistant, advanced practice registered nurse, practical nurse, or registered nurse.

(33) "Medical procedures" includes but is not limited to blood draws, insertion or removal of feeding tubes, intravenous lines, catheters, or life support.

(34) "Mental health therapist" means an individual currently licensed under Title 58 Chapter 60 as a physician engaged in the practice of mental health therapy, an advanced practice registered nurse specializing in psychiatric mental health nursing, a psychologist qualified to engage in the practice of mental health therapy, a clinical social worker, a certified social worker, a marriage and family therapist, or a professional counselor.

(35) "Neglect", which includes "severe neglect", is as defined in Sections 62A-3-301, 62A-4a-101, and 76-5-111, including but not limited to actual, attempted, or threatened:

(a) failure to provide sufficient nutrition, hydration, sleep, clothing, bedding, shelter, medical services, dental services, or educational services when the provider is responsible for providing these services to the client;

(b) failure to provide adequate client supervision;

(c) providing client services while impaired for any reason, including but not limited to being under the influence of alcohol or drugs;

(d) failure to provide care or treatment as described by a client's service or treatment plan.

(36) "On call" means immediately available to staff by telephone, and able to be present on site within one hour after a staff telephone call for assistance.

(37) "On duty" means awake, within visual or auditory proximity of clients, and immediately available to clients.

(38) "Outdoor youth program" means a youth program that is required to be licensed in accordance with Rule R501-8 to provide treatment services in an outdoor setting.

(39) "Outpatient treatment" is defined in Section 62A-2-101.

(40) "Person" includes an individual, agency, association, partnership, corporation, or governmental entity.

(41) "Passive physical restraint" means approved non-violent holding techniques that restrict a client's free movement, and are used solely to prevent a client from harming any person, animal, or property, or to allow the client to regain physical or emotional control.

(42) "Restraint" means the use of physical force or a mechanical device to restrict a client's freedom of movement or a client's normal access to his or her body, and includes the use of a drug or substance that is not prescribed by the client's physician and is used to control the client's behavior or restrict the client's freedom of movement.

(43) "Sexual abuse" or "sexual exploitation" includes but is not limited to actual, attempted, or threatened:

(a) sexual contact with a client;

(b) employing, using, persuading, inducing, enticing, or coercing a client to pose in the nude, to observe or participate in sexual acts, or to engage in any sexual or simulated sexual conduct; or

(c) an offense described in Title 76, Chapter 5, Offenses Against the Person.

(44) "Residential support" is defined in Section 62A-2-101.

(45) "Residential treatment" is defined in Section 62A-2-101.

(46) "Seclusion" means restriction of a client to a small room with minimal stimulation, to temporarily isolate a client and to allow the client to regain physical or emotional control.

(47) "Secure treatment" is defined in Section 62A-2-101.

(48) "Self-directed time-out" means a program permits a client to retreat to a quiet room in compliance with the client's request, for the purpose of allowing the client to regain physical or emotional control.

(49) "Sick" means to have a fever, an illness that may be contagious, or to be experiencing diarrhea or vomiting.

(50) "Significant criminal activity" means any act or omission resulting in: the abuse, neglect, or exploitation of a child or vulnerable adult; the death, kidnapping, or rape of any person; an assault resulting in an injury that requires additional medical assistance after treatment with basic first-aid; an assault using a dangerous weapon; a medical or other emergency; or the damage, destruction, or misappropriation of any property or service valued at $1000 or more.

(51) "Social detoxification" is defined in Section 62A-2-101.

(52) "Staff" means program directors, supervisors, employees, contractors, agents, students, interns, volunteers, or others who provide any program services.

(53) "Staff-directed time-out" means a program requires a client to retreat to a quiet room for the purpose of allowing the client to regain physical or emotional control.

(54) "Staff-in-charge" means the on duty staff, who currently meets the criteria established by the program and Section R501-2-11, who is responsible for client supervision, program services, and rule compliance during a period of time designated by the program director.

(55) "Support staff" means staff who do not directly supervise clients and who only provide support services.

(56) "Therapeutic school" is defined in Section 62A-2-101.

(57) "Treatment plan" means a written description of the therapeutic and other services an individual client requires, as determined and updated after periodic assessments by a mental health therapist.

(58) "Vulnerable Adult" is defined in Section 62A-2-101.

(59) "Youth program" is defined in Section 62A-2-101.

 

R501-2-3. Program Administration.

(1)(a) A program shall comply with this rule, R501-2, applicable categorical rules, variances issued in accordance with Section R501-1-9, and local, state and federal laws at all times, regardless of whether a deficiency or violation is observed or noted by the Office of Licensing.

(b) A program shall monitor itself and promptly identify and correct any deficiency or violation of Rule R501-2, applicable categorical rules, variances issued in accordance with Rule R501-1, and local, state and federal laws.

(2) The program shall have and comply with a current, written policy and procedure manual that addresses all rules in Rule R501-2 and all rules in the categories of licensure for which the program applies, and shall also include:

(a) program philosophy;

(b) description of long and short term goals;

(c) description of the services provided;

(d) detailed description of the population to be served;

(e) admission, exclusion, intake, and expulsion criteria and procedures;

(f) description of how the program will comply with the core and categorical rules.

(3) The program's policies and procedures manual shall be submitted to the Office of Licensing with the program's application for an initial license.

(a) The program may request in writing that the policies and procedures manual be classified as protected as indicated in subsection(4)(a).

(b) Modifications to the manual shall be submitted to the Office of Licensing prior to the effective date of any changes to the manual.

(4) Except as described in subsection(a) below, the Office of Licensing shall classify a program's policies and procedures manual as public and disclose it to the public in accordance with the Government Records Access and Management Act.

(a) Records classified as "protected" in accordance with Sections 63-2-304 and 63-2-308 may be withheld from disclosure to the public.

(5) The program shall have a written quality assurance plan, and shall document the implementation of that plan.

(6) The program shall comply with and post the following notices where they can be read by staff, clients and visitors:

(a) abuse and neglect reporting laws;

(b) Civil Rights Notice;

(c) Americans with Disability Act;

(d) Notices of Agency Action; and

(e) program license.

(7) All programs that provide services to children or vulnerable adults shall submit identifying information for background screening in accordance with Rule R501-14.

(a) The program shall have policies and procedures for the handling of staff who are denied a background screening clearance.

(8) The program shall comply with all applicable Interstate Compact Laws.

(9) The program shall not exploit clients.

(a) A client shall not be required to perform work that involves the operation or maintenance of the program or its facilities or that exploits the client.

(i) A client may be required to work in a vocational educational, vocational rehabilitation, or vocational training program that complies with all applicable labor laws, when the work is required by the client's individual service or treatment plan.

(ii) A client may be required to participate in housekeeping and hygiene activities, including but not limited to cleaning the client's own sleeping area, the client's proportionate share of program common areas, cleaning up after the client's own activities, and laundering the client's own clothes.

(iii) A client may be required to participate in the client's proportionate share of meal preparation and meal clean-up activities.

(iv) A client may be required to participate in community service work for a public or non-profit organization that does not involve the operation or maintenance of the program or its facilities or benefit the program, when the work is required by the client's individual service or treatment plan.

(b) Except as provided by Subsection R501-2-3(9)(a)(i) through(iv), a client who chooses to perform work that involves the operation or maintenance of the program or its facilities or benefits the program shall be compensated.

(c) The program shall comply with State and Federal laws regarding the compensation and safety of staff and clients on its workforce, including but not limited to laws regarding minimum wage requirements.

(10) Information provided to clients, guardians, media, and the public shall be accurate and factual. Requests for information received from clients and guardians shall be responded to within 5 business days.

 

R501-2-4. Financial Requirements.

A program shall provide a written disclosure of all fees and expenses a client or a client's guardian may incur, and identify which fees may be non-refundable, before accepting any payment, entering any contract to provide client services, or admitting a client to the program.

A program shall provide an itemized accounting of actual expenditures made on behalf of each client before requiring reimbursement from the client or the client's guardian, except a program is not required to provide an itemized accounting of expenditures that have previously been disclosed to and approved by the client or the client's guardian in writing.

The program shall not handle the personal business affairs of a client, including but not limited to borrowing or lending money, withdrawing assets from a client's account, or co-signing applications or notes, unless the program is first court-appointed as the client's guardian or conservator and acting within the limits of that appointment, except for a provider who is certified by the Social Security Administration and designated as the client's representative payee.

A client's personal funds shall not be commingled with the program's funds.

A program that maintains clients' personal funds for the client's use shall have a section in its policy and procedure manual regarding access to and use of clients' personal funds.

(a) A program's policy and procedures regarding a client's personal funds shall be admission.

(b) A program shall permit a client to access the client's personal funds in accordance with its policy and procedure manual.

(c) A program shall maintain an accurate log of all funds deposited and all withdrawals made for the personal use of each client.

(d) A program shall obtain the signature of the client or client's guardian verifying receipt of each withdrawal made for the personal use of each client.

(e) Receipts for purchases of over $20.00 shall be signed by the client or guardian, and direct care staff, and maintained with the log.

 

R501-2-5. Governance.

(1) The program shall have a governing body that is responsible for and has authority over program policies and procedures. The governing body's responsibilities shall include the following:

(a) to ensure program policy and procedures compliance;

(b) to ensure continual compliance with local, state and federal requirements;

(c) to notify the Office of Licensing prior to changes in program purpose or services, and no later than one business day after changes in program administration;

(d) to ensure that the program is fiscally and operationally sound, by providing written verification by an independent financial professional by means of a Financial Opinion Statement that offers an unqualified opinion that the program's financial statements are presented fairly. A financial audit of the program by an independent CPA may be substituted for a Financial Opinion Statement;

(e) to ensure that the program has adequate staffing as identified on the organizational chart and categorical rules;

(f) to ensure that the program has general or commercial general liability insurance, professional liability insurance, motor vehicle insurance for each vehicle used to transport clients, worker's compensation insurance in accordance with Section 34A-2-101, et seq., and fire insurance; and

(g) to provide the Office of Licensing with current certificates of insurance or self-insurance that include a provision requiring the insurer to notify the Office of Licensing in the event that policy coverage is amended or cancelled.

(2) The governing body shall be:

(a) a Board of Directors in a non-profit organization;

(i) a non-profit organization shall document its legal status;

(b) commissioners or appointed officials of a governmental unit;

(i) a publicly operated program shall document its statutory authorization; or

(c) Board of Directors or individual owners of a for-profit organization;

(i) a for-profit organization shall document its ownership and legal status.

(3) The program shall have a current list of all members of its governing body, indicating the name, address and term of each member.

(4) The program shall have an organization chart which identifies operating units of the program and their inter-relationships. The chart shall define lines of authority and responsibility for all program staff and identifies by name the staff person who fills each position.

(5) When the governing body is composed of more than one person, the governing body shall establish written by-laws, hold formal meetings at least twice a year, and maintain written minutes, which shall be available to the Office of Licensing, to include:

(a) attendance;

(b) date;

(c) agenda items; and

(d) actions.

 

R501-2-6. Record Keeping.

(1) The program shall have a written record for each client, which shall include:

(a) the client's full name, gender, date of birth, description, and other identifying information;

(b) the client's guardian, if any, and the guardian's full name, address, and telephone numbers, and copies of documents establishing guardianship;

(c) client's application, all contracts and agreements with the program that are signed by the client or the client's guardian, intake evaluation and assessments;

(d) dates of placement and discharge, who placed client in program, and to whom client was discharged;

(i) this subsection(d) does not apply to child placing adoption agencies;

(e) the client's background information, including:

(i) intake screening and initial assessment;

(ii) legal status;

(iii) emergency contact with name, address and telephone number; and

(iv) in residential programs and programs where clients consume medications, a current, full-face photo kept at the location where medications are administered;

(f) health records of a client, including:

(i) in programs serving children, immunizations;

(ii) medical needs, medication, and allergies; and

(iii) in residential programs, physical, dental, hearing, and vision examinations;

(g) signed consent forms for treatment;

(h) signed and completed release of information form(s);

(i) the client's individual treatment or service plan;

(j) the client's progress records;

(k) a copy of all incident reports involving the client;

(l) a copy of all search reports involving the client;

(m) a copy of all transfer and placement reports involving the client;

(n) a record of family visits; and

(o) a record of attendance and absences.

(2) The program shall have a personnel file for each staff, which shall include:

(a) his or her job description;

(b) application for employment or resume;

(c) current address and telephone numbers;

(d) copies of required credentials and certifications, including but not limited to diplomas and licenses;

(e) verification of work experience and qualifications for the staff position held;

(f) food handler permit, if staff prepare food for clients;

(g) training record;

(h) annual performance evaluations and proficiency evaluations;

(i) documentation of disciplinary actions;

(j) completed IRS I-9 Form;

(k) current background screening approval verifications;

(l) a signed copy of the current Department of Human Services Provider Code of Conduct, for programs that are contracted to provide services to the Department of any or its Divisions; and

(m) copy of current driver's license for all staff who transport clients.

(3) A program shall retain all records relating to a client or staff for a minimum of 8 years after the date the client or staff is discharged, terminated, or otherwise departs the program, and for a minimum of 4 years after a client or staff who is a child attains the age of 18 years.

(a) Current staff and client records shall be maintained on-site and shall be immediately available to the Office of Licensing upon request.

(b) Former staff and client records may be maintained off-site and made available to the Office of Licensing within 24 hours of request.

(4) All manuals and other program records shall be available to the Office of Licensing upon request for a minimum of 8 years from the date they expired or were superceded. A program:

(a) shall maintain copies of all written reports and certificates of clearance issued by the fire inspector;

(b) that is required to have fire sprinklers shall maintain copies of all written reports issued by the fire sprinkler inspector;

(c) shall maintain copies of all written reports and certificates issued by the building inspector; and

(d) shall maintain copies of all written reports and certificates issued by the local health inspector.

(5)(a) Staff and client records shall be maintained in locked storage when not in active use.

(b) Unlocked staff and client records shall not be left unattended. Direct care staff shall remain within immediate reach of unlocked records at all times.

(6) The on duty staff-in-charge shall have access to all locked files, including computer files, and make them immediately available to the Office of Licensing upon request.

A program that does not grant a staff-in-charge access to all locked staff files shall have an on-call staff with access and shall make staff files available to the Office of Licensing within one hour of a request.

(7) A licensed program with more than one site may locate its staff files at one licensed site, however client files and other records shall be available at the licensed site where the client resides, or in non-residential programs, where the client receives services.

(8) A current roster of all clients shall be available on site at all times.

The roster shall include each client's name, date of birth, sex, emergency contact information, and date of admission.

In a residential program, the current location of any client who is off-site shall be maintained in the roster or a log established for that purpose.

(9) A program's rules shall be provided to clients and clients' guardians, and shall be available to a client's clergy or attorney upon request.

 

R501-2-7. Direct Service Management.

(a) A program shall have written policies and procedures that describe the appropriate treatment of clients, and shall prohibit the abuse, neglect, maltreatment, and exploitation of clients.

(b) Staff shall not abuse, neglect, maltreat, or exploit any client through any act or omission.

(c) Staff shall not encourage or fail to deter the acts or omissions of another that abuse, neglect, maltreat, or exploit any client.

(d) Staff shall not engage in criminal conduct.

(2) The program shall have a written eligibility policy and procedure that shall include:

(a) legal status;

(b) age and sex of client;

(c) client needs or problems best addressed by program;

(d) program limitations; and

(e) placement.

(3) Admission policy and procedures shall include:

(a) written intake screening conducted prior to a client's admission that determines whether a prospective client meets the program's eligibility standards;

(b) age of clients served, as approved by the Office of Licensing;

(i) a program shall not provide services to children and adults without first obtaining the written approval of the Office of Licensing;

(ii) a residential program shall not locate the bedrooms or bathrooms of children on the same wing, corridor, or floor with adult clients;

A program providing services only to women and their children is excepted from this subsection(3)(b)(ii).

A program authorized to provide services to an adult in the same facility as a child in accordance with Section 62A-2-106(1)(a)(iii) and Subsection R501-19-11(5) is excepted from this subsection(3)(b)(ii).

(iii) a program shall not permit children to participate in any activity, including but not limited to treatment, counseling, dining, education, recreation, free time, or using restroom facilities, on the same wing, corridor, floor, or other location, with adults, without first obtaining written approval from the Office of Licensing of its policy and procedures designed to safely separate children from adult clients;

(A) A program providing services only to women and their children is excepted from this subsection(3)(b)(iii).

(c) pre-placement requirements;

(d) self-admission;

(e) all items referenced in client manual under subsection(6);

(f) notification of client's guardian; and the program shall not admit a client with a medical emergency or a client who needs medical detoxification from drugs or alcohol.

(4) A program shall conduct a written intake screening prior to admitting a client.

(a) The intake screening shall determine whether:

(i) the client applicant satisfies the program's written eligibility policy; and

(ii) the program provides the services needed by the client applicant.

(5) The program shall complete a written assessment of each client.

(a) The assessment of each client shall be conducted:

(i) by a mental health therapist, in programs that provide treatment; or

(ii) by the client's direct care team, as defined in program policy, in programs that do not provide treatment; and

(iii) within 30 calendar days of admission to determine whether the program remains an appropriate placement to meet the client's physical, emotional, social, educational, recreational, and other needs.

(b) The assessment shall evaluate each client's health and family history, including but not limited to a self-harm assessment, medical, social, psychological, developmental, vocational and educational factors.

(c) The written assessment shall include a detailed description of the client's needs.

(6) A current client manual shall be provided to each client or each client's guardian before the program accepts any non-refundable payment or enters any contract to provide client services. The manual shall include detailed descriptions of:

(a) client expulsion criteria and procedures;

(b) services and activities provided on site and off site;

(c) methods of providing supervision of clients on-site and off site;

(d) the rules of the program, including but not limited to rules regarding discipline and personal possessions;

(e) the program's policy and procedures regarding:

(i) attendance and absenteeism;

(ii) visits to and from family, friends, and others;

(iii) vacation and holidays;

(iv) sending and receipt of mail and email;

(v) sending and receipt of gifts; and

(vi) making and receiving telephone calls;

(f) the program's policy and procedures regarding behavior management;

(g) the program's policy and procedures regarding contraband;

(h) the program's policy and procedures regarding searches;

(i) the program's food service and samples of actual menus;

(j) the program's physical education and recreational activities;

(k) the program's client rights statement;

(l) the program's weapons policy;

(m) the program's client grievance policy, including an appeal process; and

(n) the name and contact information for the Office of Licensing.

(7)(a) A written agreement between the program and the client or the client's guardian shall be completed and signed by all parties before the program accepts any payment from the client or the client's guardian.

A copy of the signed agreement shall be provided to the client or the client's guardian, and a copy shall be kept in the client's file.

(c) The agreement shall include:

(i) services to be provided and cost of service;

(ii) the client or the client's guardian's consent to participate in each program activity;

(iii) the client or the client's guardian's authorization to obtain emergency medical care for the client; and

(iv) the duration of the agreement.

(8)(a) A client's written individualized treatment or service plan shall include:

(i) the title of direct care staff assigned to provide services to the client, including but not limited to staff having responsibility for the development, implementation, and review of the plan;

(ii) the client's measurable long and short term goals and objectives;

(iii) evidence by way of client or guardian signature that input from the client or the client's guardian was integrated in identifying goals and objectives;

(iv) services, and treatment;

(v) methods for evaluation;

(vi) criteria for discharge; and

(vii) transition and follow-up plans.

(b) An individual treatment or service plan shall be developed, signed, and dated within 30 days of each client's admission by:

(i) a mental health therapist or an intern in a supervised clinical training internship who is certified under Title 58 chapter 60;

(ii) a "qualified mental retardation professional", as that term is defined in 42 CFR 483.430, for a client served through a contract between the program and DSPD; or

(iii) a Therapeutic Recreation Specialist who is licensed under Title 58 chapter 40, for clients in Adult Day Care programs.

(c) Each client's treatment or service plan shall be reviewed by:

(i) the mental health therapist as often as stated in the treatment or service plan, and no less than once every 3 months;

(ii) the "qualified mental retardation professional", for a client served through a contract between the program and DSPD, as often as stated in the treatment or service plan and no less than once every year; or

(iii) a Therapeutic Recreation Specialist who is licensed under Title 58 chapter 40, for clients in Adult Day Care programs.

(d) Each review shall include an assessment of the appropriateness of the program to continue to provide the services needed by the client.

(e) The client and the client's guardian shall be provided an opportunity to participate in each review and revision of the plan.

(9) (a) Reports on the progress of the client shall be provided to the client or the client's guardian.

(b) Treatment and service records shall be provided to the client or the client's guardian within two weeks of request.

(10) Treatment progress notes and service record entries shall include:

(a) identification of the program;

(b) date and duration of services provided, including but not limited to therapeutic, treatment, medical, educational, and recreational services;

(c) description of service provided; and

(d) a description of client progress or lack of progress in the achievement of treatment or service goals or objectives.

(11) All treatment progress notes and service record entries shall be signed and dated by the author, and shall include the author's title and the time they are written.

(12) Client Transfer, Withdrawal, or Discharge.

(a) The program shall develop a written individual discharge plan for each client.

(b) The individual discharge plan shall identify the client's ongoing needs and resources that may be available to the client.

(c) The plan shall be developed with the participation of the client or the client's guardian.

(d) A copy of the written individual discharge plan shall be provided to the client or the client's guardian upon the client's transfer, withdrawal, or discharge from the program.

(e) Within fifteen calendar days after each client transfers, withdraws, is discharged, or otherwise leaves the program, a discharge report shall be completed and placed in the client's file. The report shall include the:

(i) reason for discharge, withdrawal, or transfer;

(ii) summary of services provided;

(iii) evaluation of achievement of treatment goals or objectives;

(iv) signature and title of staff preparing the report; and

(v) date of discharge, withdrawal, or transfer.

The program shall have and comply with written policy and procedures concerning the unplanned discharge or withdrawal of a client.

(13)(a) The program shall have written policies and procedures regarding incident reports that shall include:

(i) An incident report documenting all incidents, such as deaths, medical emergencies, injuries of unknown origin, suicide attempts, suicide, fights, physical confrontations, situations involving the use of passive physical restraints, alleged or suspected incidents of abuse, neglect, or exploitation, unauthorized client absences from programs serving children or vulnerable adults, unusual incidents, searches performed when the client or client's guardian has not signed a written consent, and other situations affecting the health or safety of clients or staff, shall be signed by the staff involved and provided to the program director or acting director within 12 hours of the incident.

(ii) An incident report documenting the use of physical restraint, staff-directed time-out, seclusion, or any behavior modification technique that results in an injury to any person, shall be signed by the staff involved and provided to the program director or acting director within 12 hours of the incident, and shall include a detailed description of:

(A) the client's behavior before, during, and after the intervention;

(B) staff who requested, required, supervised, and witnessed the behavior or the intervention;

(C) staff attempts to de-escalate the behavior;

(D) the length of time that de-escalation was attempted;

(E) the date and time the intervention technique was started and completed;

(F) the intervention techniques used;

(G) supervisory follow-up with the staff; and

(H) follow-up with the client.

(iii) The program director or acting director shall review and sign each incident report, and document any follow-up action taken, including but not limited to staff training, staff discipline, or assessment of the appropriateness of the program to continue to provide the services needed by the client.

(b) A program shall verbally report an incident that involves death, or an emergency that may make continued provision of services impossible or impracticable, to the Office of Licensing and the client's guardian within 12 hours of the incident.

(c) A preliminary written report of an incident that involves the application of physical restraint that results in any injury; allegations of abuse, neglect, maltreatment or exploitation; medical emergency; death; a fire or other emergency that may make continued provision of services impossible or impracticable; shall be signed by the staff involved and submitted to the Office of Licensing within 24 hours of the incident; and a final written report shall be submitted to the Office of Licensing within 15 calendar days of the incident.

(d) A program shall immediately report an incident that involves death or significant criminal activity to the local law enforcement agency, except when prohibited by 42 CFR Part 2.

(e) A program shall report any alleged misconduct by staff that are licensed by state or local authorities, including but not limited to the Division of Occupational and Professional Licensing, to the applicable licensing authority within 15 calendar days of knowledge of the incident.

(14) The Office of Licensing may report a licensee's or staff's misconduct to law enforcement, clients, and clients' legal representatives.

(15)(a) A client who has a medical emergency, or who requests the services of a medical practitioner, shall receive an immediate assessment by a certified wilderness first responder, certified EMT, or a medical practitioner.

(b) The program shall comply with the recommendations of the certified wilderness first responder, certified EMT, or medical practitioner.

(c) The supervisor or staff-in-charge shall complete an incident report that describes the medical emergency or client request for medical services, includes the name and title of the individual performing the assessment, describes the individual's conclusions and recommendations, and attaches any documents regarding the incident and assessment.

(16)(a) The program shall have and comply with a written policy and procedures describing how clients will be transferred or placed in the event that program becomes unable to provide services due to a license sanction, court action, fire, or other emergency that makes continued provision of services impossible or impracticable.

(b) A written report documenting client transfers or placements shall include:

(i) the date, time, and circumstances surrounding the transfer or placement;

(ii) the client and staff involved;

(iii) communications with the client's guardian;

(iv) methods of transfer used, including transportation and safety plans;

(v) verification that the client's guardian, if any, has accepted physical custody of the client or approved the transfer of physical custody of the client to an individual designated by the guardian in writing;

(vi) date, signature and title of staff preparing report; and

(vii) date and signature of the program director approving the report.

(17) The program's grievance policy shall describe how a grievance may be made, who shall investigate and complete a written report regarding each grievance, and an appeal process.

(a) The program, its governing body and its staff shall not retaliate against any person who makes a complaint or grievance.

(b) Grievances shall be retained in grieving client's or grieving staff's file, and a copy shall be retained in a separate file documenting all grievances together with the investigation and resolution.

(18) Changes to the program's services, policies and procedures shall be disclosed to clients or clients' guardians prior to any change.

 

R501-2-8. Off-site Activities.

(1) A program that offers off-site activities for clients shall describe in the program's policies and procedures manual which types of off-site activities, including but not limited to specific types of mountain sports, water sports, shopping trips, and field trips, are permitted and which are prohibited, and shall:

(a) address risk factors associated with taking clients off-site for each type of activity permitted by the program;

(b) address risk factors associated with the client population that may participate in off-site activities;

(c) identify high-risk clients and require staff to remain within sight or hearing of high-risk clients;

(d) describe the minimum direct care staff-to-client ratio required for each type of activity permitted by the program, which shall never be less than the minimum direct care staff-to-client ratio required by categorical rule;

(e) describe what physical and behavioral prerequisites a client must meet in order to participate in each type of activity permitted by the program; and

(f) include a safety plan, including but not limited to communication, emergency and evacuation procedures, for each type of activity permitted by the program.

(2) A program shall obtain the written consent of the adult client or the client's guardian for each type of off-site activity prior to permitting the client to participate in the activity, but is not required to obtain an additional consent each time the client participates in the same activity.

(3) Staff involved in the off-site activity shall be familiar with the location and activity.

(a) A program may contract with an experienced professional guide to conduct an activity as long as the client's legal guardian grants permission and the program maintains responsibility for the health and safety of the participants.

(4) A program shall provide safety equipment, supplies, staff training, and client training for each person participating in the activity.

 

R501-2-9. Behavior Management.

(1) The program policies and procedures shall describe all methods of behavior management permitted by the program. These shall include:

(a) definition of appropriate and inappropriate behaviors;

(b) acceptable staff responses to inappropriate behaviors;

(i) staff shall only use behavior management techniques appropriate for the age, behavior, needs, and developmental level of a client;

(ii) staff shall only use behavior management techniques that are positive, consistent, and that promote self-control, self-esteem, and independence;

(iii) staff shall not use physical work assignments or activities that inflict pain as behavior management techniques;

(A) a physical work assignment or activity that results in minor sore muscles does not violate subsection(1)(b)(iii);

(iv) staff shall not abuse, threaten, humiliate, ridicule, degrade, or frighten a client;

(v) staff shall not deny a client medical care, food, hydration, clothing, bedding, sleep, toilet and bathing facilities, or any clients' rights;

(vi) staff shall not use nor permit the use of a mechanical restraint, chemical restraint, physical force, or the infliction of pain to discipline, coerce, punish, or retaliate against a client;

(vii) staff shall not place nor permit another to place anything on a client's face, over a client's head, or in a client's mouth to discipline, coerce, punish, or retaliate against a client;

(c) staff shall use the least restrictive method of behavior management available to control a situation; and

(d) staff shall not use behavior management techniques that are not specifically authorized by the program's written policy and procedures.

(2) Staff shall receive training relative to behavior management at least annually.

(3)(a) Staff shall not use nor permit the use of any physical restraint with the exception of passive physical restraint.

Passive physical restraint shall be used only as a temporary means of physical containment to protect the client, other persons, or property from harm.

(c) Passive physical restraint shall not be used to discipline, coerce, punish, or retaliate against a client.

(d) Passive physical restraint shall be documented in an incident report.

(e) Passive physical restraint shall be applied only by staff who are trained in accordance with the non-violent intervention strategies of a State, regional or national recognized program.

(f) Passive physical restraint shall be applied only as long as necessary to calm the client, and shall not exceed 30 minutes unless a mental health therapist, a medical practitioner, or a behavior consultant in a program that is under exclusive contract with DSPD and provides services only to DSPD clients, remains present on site, evaluates the client, and determines that the restraint remains necessary.

(4)(a) A staff-directed time-out or a self-directed time-out is only used when a client's behavior is disruptive to a client's ability to participate in the activity, or as an intervention when the client poses a risk of harm to a person or property.

(b) A time out shall not be used to coerce, punish, or retaliate against a client.

(c) A staff-directed time-out shall be documented in an incident report.

(d) If a client is placed in a staff-directed time-out more than four times in any twenty-four hour period, a review is conducted by the mental health therapist, medical practitioner, or a behavior consultant in a program that is under exclusive contract with DSPD and provides services only to DSPD clients, to determine the suitability of the client remaining in the program.

(e) Any one time-out shall not exceed 30 minutes in duration unless a mental health therapist, a medical practitioner, or a behavior consultant in a program that is under exclusive contract with DSPD and provides services only to DSPD clients, remains present on site, evaluates the client, and determines that the time-out remains necessary.

(f) A staff who is responsible for monitoring a client in a staff-directed time-out shall have no other immediate responsibilities and is required to maintain continuous visual or auditory contact with a client.

(5)(a) Seclusion may only be used when a client's behavior is disruptive to a client's ability to participate in the activity, or as an intervention when the client poses a high risk of harm to a person or property, and a less restrictive method of behavior management is ineffective.

(b) Seclusion shall not be used to discipline, coerce, punish, or retaliate against a client.

(c) Seclusion shall be documented in an incident report.

(d) If a client is placed in seclusion more than 2 times in any twenty-four hour period, a review is conducted by a mental health therapist, a medical practitioner, or a behavior consultant in a program that is under exclusive contract with DSPD and provides services only to DSPD clients, to determine the suitability of the client remaining in the program.

(e) Any one seclusion shall not exceed the time required for the client to gain control of the client's emotions and actions, and in no event shall the seclusion exceed 2 hours in duration unless a mental health therapist, a medical practitioner, or a behavior consultant in a program that is under exclusive contract with DSPD and provides services only to DSPD clients, remains present on site, evaluates the client, and determines that the seclusion remains necessary.

(f) A staff who is responsible for monitoring a client in seclusion shall have no other immediate responsibilities and is required to maintain continuous visual and auditory contact with a client.

(g) Seclusion shall not be used in any:

(i) therapeutic school, or

(ii) non-residential program.

(6) If there is any type of emergency, such as a fire alarm or evacuation notification, clients in time-out or seclusion shall immediately be released and follow the safety plan.

(7) A client who is placed in a staff-directed time-out or seclusion shall not be in possession of potentially harmful objects or materials, such as articles of clothing that could present a risk or harm.

(a) A client who has expressed any suicidal or self-harm ideation or behavior shall be visually monitored by staff until a mental health therapist evaluates the client and makes further recommendations.

(b) A client in time-out or seclusion shall be provided with clothing that preserves the comfort, modesty, and dignity of the client.

(8) Toilet facilities shall be provided for a client who is in time-out or seclusion.

(9)(a) Time-out rooms shall not be located in closets, bathrooms, unfinished basements, unfinished attics, or boxes.

(b) Seclusion rooms shall not be located in closets, bathrooms, bedrooms, unfinished basements, unfinished attics, or boxes.

(c) A seclusion room shall be unfurnished and shall contain no equipment or materials that a client may use to inflict harm upon any person or property.

(d) A room used for time-out or seclusion shall be wide enough and deep enough to allow the client to lie prone with arms extended without touching the walls, with a ceiling height of at least 7 feet.

(e) A room used for time-out or seclusion shall have either natural or mechanical ventilation, and shall be maintained at no less than 65 degrees and no more than 80 degrees.

(f) A room used for seclusion shall be equipped with a break resistant window or camera that allows for full observation of all areas of the room.

(g) A room used for time-outs or seclusion shall not have locking capability, except:

(i) after receiving the prior written approval of the Office of Licensing, a program may equip a time-out or seclusion room with a magnetic lock that is connected with the program's alarm system and that automatically unlocks in the event of an emergency; and

(ii) after receiving the prior written approval of the fire marshal, a program may use a magnetic lock in a time-out or seclusion room that is connected with the program's alarm system and that automatically unlocks in the event of an emergency.

(10) The program's mental health therapist shall be responsible for the supervision of the program's behavior management procedures.

(a) A program that is under exclusive contract with DSPD and provides services only to DSPD clients may utilize the services of a "behavior consultant" instead of a mental health therapist.

 

R501-2-10. Rights of Clients.

(1) The program policies and procedures shall describe clients' rights, which shall include but not be limited to:

(a) the right to confidentiality of information about prospective, current and former clients, and the right to confidentiality of records concerning prospective, current and former clients, except when disclosure is required by law or requested by the client's guardian or an adult client;

(b) the right to receive medical care, treatment services, nutritious food, and in residential programs, clean clothing and safe shelter;

(c) the right to be informed of the reasons for an involuntary termination, appeals processes in programs that permit appeals of involuntary terminations, and the criteria for re-admission to the program in programs that permit readmission;

(d) the right to be treated with courtesy and professionalism by staff;

(e) the right to protection from harm or acts of violence, including protection from physical, verbal, sexual, and emotional abuse, neglect, maltreatment, exploitation, or inhumane treatment;

(f) the right to be informed of the program's rules of conduct;

(g) the right to be informed of the program's fees and other costs that the client is responsible for paying;

(h) the right to be informed of and invoke, without repercussion or retribution, complaint, grievance and appeal procedures, including but not limited to appeals of level changes and service changes;

(i) the right to protection from discrimination based upon the client's race, color, national origin, culture, religion, sex, sexual orientation, age, political affiliation, or disability;

(j) the right to be treated with dignity, which shall include but not be limited to the right to reasonable personal privacy, the right to have the client's opinions regarding the client's treatment and future considered and, to the greatest extent possible, honored;

(k) the right to communicate with and have visitors, except for those individuals whose communication and visitation rights have been restricted through the courts, the client's guardian, the client's mental health therapist, or the client's "qualified mental retardation professional" for a client served through a contract between the program and DSPD;

(i) the right to communication with and visits from the client's guardian, attorney, physician, and clergy shall not be restricted;

(l) the right to send and receive private, unopened, uncensored mail to and from the client's guardian, attorney, physician, clergy, and the Office of Licensing;

(i) a program may require a client to open mail from individuals other than the client's guardian, attorney, physician, clergy, or the Office of Licensing in the presence of program staff to verify that no contraband is present, but may not read the client's mail,

(ii) a program that restricts a client from receiving mail from any individual other than the client's guardian, attorney, physician, clergy, or the Office of Licensing shall return the mail, unopened, to the sender; and

(m) the right to be informed of the program sanctions and consequences that have been reviewed and approved by the Office of Licensing.

(2) Each client shall be informed of the Clients' Rights statement verbally and in writing no later than the time of intake and admission. A copy of the Client's Rights statement shall be signed by the client and the client's guardian, and shall be maintained in the client's file.

(3) The program's Client's Rights statement shall be posted or provided to clients and clients' guardians, together with the phone number of the Office of Licensing.

 

R501-2-11. Personnel Administration.

(1) The program shall have written personnel policies and procedures regarding:

(a) employee grievances;

(b) supervision and lines of authority;

(c) orientation and training;

(d) rules of conduct;

(e) mandatory abuse, neglect and exploitation reporting;

(f) staff discipline; and

(g) sexual and personal harassment.

(2) Each program site shall have a minimum of one supervisor or staff-in-charge on-site at all times.

(3) The program shall follow a written staff to client ratio, which shall meet specific client and program needs. The direct care staff to client ratio shall meet or exceed the requirements set forth in the applicable categorical rules.

(4) The program shall have a written job description for each position, which includes a specific statement of duties and responsibilities and the minimum level of education, training and work experience required.

(5) The governing body of the program shall designate one or more program directors, acting directors, or clinical directors who shall maintain responsibility for the on-site daily administration and operation of the program.

(6) All direct care staff shall have within 90 days of the date of hire:

(a) current certification in standard first aid;

(b) current certification in CPR;

(c) documented training in behavior management techniques, including passive restraint techniques by a certified instructor, if program staff use any passive restraint techniques; and

(d) emergency procedures.

(7) In addition to completing the requirements Subsection R501-2-11(6):

(a) The director, clinical director, and all acting directors who maintain responsibility for the on-site administration and operation of the program shall:

(i) be at least 25 years of age;

(ii) have a BA or BS social services degree, or a minimum of three years of documented training or experience in providing the program services, and have a minimum of two years of social service program management experience.

(b) Each supervisor shall have:

(i) a minimum of one year of documented competency and proficiency performing on-duty direct-care program services; and

(ii) documentation of meeting the minimum qualifications for their job description.

(c) A staff-in-charge shall have:

(i) a minimum of six months of documented competency and proficiency performing on-duty, direct-care program services; and

(ii) documentation of meeting the minimum qualifications for their job description.

(8) Each staff with direct access to a client shall be directly supervised by a supervisor until the staff:

(a) achieves the qualifications, competency and proficiency requirements, and training requirements of the applicable job description;

(b) receives current certification in standard first aid;

(c) receives current certification in CPR;

(d) for programs where a background screening is required, a current background screening clearance; and

(e) all training listed in Subsection R501-2-11(9).

(9) Staff shall receive and document the following annual training and requirements:

(a) behavior management;

(b) passive restraint techniques by a certified instructor, if program staff use any passive restraint techniques;

(c) client searches, if program staff conduct any searches;

(d) suicide prevention;

(e) successfully completes annual training directly related to providing program services;

(f) completes a current annual background screening clearance through the Office of Licensing in programs requiring a background screening; and

(g) reads, signs, and demonstrates a working knowledge of:

(i) Rules R501-2 Core Rules, R501-1 General Provisions, R501-14 Background Screening;

(ii) the applicable categorical rules;

(iii) the current program policy and procedure manual;

(iv) the current program client manual;

(v) emergency procedures; and

(vi) universal precautions for infectious and communicable diseases.

(10) A program shall have and comply with a policy to inform direct care staff of client needs, including but not limited to:

(a) therapeutic goals of each client; and

(b) specific techniques to actively support the service plan or the treatment plan.

(11) The program shall have policy and procedures regarding contraband, which shall include:

(a) a definition of contraband that includes but is not limited to drugs, syringes, alcohol, razor blades, firearms, knives, and explosives;

(b) confiscation and disposal or return of contraband;

(c) notifications to local law enforcement; and

(d) notifications to a client's guardian.

(12) A program shall have and comply with a written policy and procedures regarding searches of a client or a client's property, which shall include:

(a) a program shall not conduct a search of a client's property or body without obtaining the written consent of the client or the client's guardian at the time of admission that describes the program's search policies and procedures;

(b) staff shall maintain the dignity of each client by conducting each search of a client's body in a private room, by two staff members of the same gender as the client;

(c) no searches shall be made except in accordance with the program's approved manual;

(d) no search shall be performed unless required for the safety of the client or another individual, or to locate and confiscate contraband;

(e) a search shall be made in the least intrusive manner possible;

(f) a description of what type of searches will and will not be permitted;

(g) staff conducting a permitted search shall complete, date, and sign a report describing the reason for the search, the time and date of the search, witnesses to the search, and the results of the search; and

(h) a permitted strip search shall be conducted only if:

(i) staff has reason to believe, after a pat-down search, that contraband may be found;

(ii) the circumstances are first discussed with the program director;

(iii) the program director authorizes the search;

(iv) the client is required to remove clothing and step away from the clothing so that staff may search the clothing;

(v) the client's body is not touched by any person;

(vi) the client's privacy is preserved; and

(vii) body cavity searches, except for requiring a client to open the client's mouth for a visual search, are prohibited.

(13) The Director of the Office of Licensing, or the Director's designee, may require a psychological examination of a person associated with the licensee as defined in 62A-2-101(24) if that person exhibits behavior that may pose a risk of harm to a child or vulnerable adult.

(a) The Director or the Director's designee may require a person associated with the licensee to:

(i) obtain and pay for a psychological examination from a currently licensed psychologist or psychiatrist who is not affiliated with the program; and

(ii) authorize the psychologist or psychiatrist to submit the examination findings and report directly to the Office of Licensing.

(b) A program's staff member or staff applicant who is required to obtain a psychological examination under this section shall have no unsupervised direct access to a client until after:

(i) a psychologist or psychiatrist examines the staff member or staff applicant; and

(ii) submits a report to the Office of Licensing that indicates the staff member or staff applicant does not pose a risk of harm to a child or vulnerable adult.

 

R501-2-12. Medication and Medical Procedures.

(1) A program shall not provide prescription or non-prescription medications to clients and shall not permit the self-administration of prescription or non-prescription medications except as specifically described in the program's policy and procedures manual and approved by the Office of Licensing.

(2)(a) A program shall not administer or permit any person to administer any medical procedures at the program site.

(b) Subsection(2)(a) shall not apply to:

(i) administration of medication in accordance with Subsection R501-2-12(3);

(iii) medical procedures performed by a medical practitioner or certified emergency medical technician;

(iv) medical procedures performed by unlicensed assistive personnel trained and supervised by a nurse in accordance with the Nurse Practice Act and Rule 156-31b; or

(v) medical procedures performed by a health care facility that is licensed by the Department of Health.

(3)(a) A program shall keep all prescription and non-prescription medications in locked storage when not in active use.

(b) A client who requires immediate access to the client's medication, including but not limited to a client with asthma or diabetes, may be permitted to carry a single dose of medication for active use.

(4) Medications in active use shall not be left unattended.

(5) Non-prescription medications shall be stored in their original manufacturer's packaging together with manufacturer's directions and warnings.

(6) Programs only serving adults who are capable of managing their own resources and carrying out the activities of daily living may develop policies approved by the Office of Licensing that permit the adult to posses and manage their own medication. The program will monitor the adult clients management of their medication.

(7)(a) Prescription medications shall be stored in their original pharmacy packaging together with the pharmacy label, directions and warnings.

(b) A medical practitioner may repackage no more than one week's worth of a client's prescription medication into individual dose packages, each of which shall be labeled with the client's name, the name of the medication, and the time, date, and dosage that the medication is to be administered.

(c) Individual dose packages shall be stored together with the original pharmacy packaging and pharmacy label, directions and warnings.

(8) The staff-in-charge or a staff with documented training in medication procedures that is designated by the staff-in-charge shall:

(a) administer or oversee the self-administration of prescription medications only as prescribed by a medical practitioner;

(b) administer or oversee the self-administration of non-prescription medications only as directed by the manufacturer;

(c) observe the client consume any medication;

(d) maintain an individual client medication log, which shall include the client's name and photograph, medication, time and dosage administered, effects of the medication, and initial or signature of client and staff administering medication; and

(e) immediately notify a client's physician of any reactions to medications that are severe or that are not expected according to warnings on prescription or non-prescription labels.

(9) Each client medication log shall be maintained together with the medication while the client is actively enrolled in the program, and transferred to the client's file when the client leaves the program.

(10) Upon discharge from a program, the program shall transfer a client's unused medications to the client's guardian or, if the client has no guardian, to the client.

(11) Unused or expired medications shall be destroyed by two direct care staff, and the destruction shall be documented.

(12)(a) A program shall inform the client's guardian of any emergency medical treatment no later than 48 hours after treatment commences.

(b) Except for minor first aid treatment, a program shall obtain the prior written consent of the client's guardian for any non-emergency medical treatment, including the administration of medication not provided by the guardian.

 

R501-2-13. Infectious Disease.

(1) The program shall have written policies and procedures designed to prevent, or control infectious and communicable diseases, including but not limited to AIDS, chickenpox, Gonorrhea, Hepatitis, HIV, Measles, Meningitis, Mumps, Rabies, Syphilis, Tuberculosis, or suspected or confirmed outbreaks of food-borne or water-borne disease in the facility in accordance with local, state and federal health standards.

(a) The program shall immediately report any individual suffering from or suspected of having a disease that is infectious or communicable to the County Health Department in accordance with Section 26-6-6 and Rule R386-702.

(2) A program shall develop written policies and procedures requiring the use of universal precautions to respond to incidents involving bodily fluids, which shall include proper clean-up procedures as recommended by the local health department.

(3) The program shall provide universal precautions training to all staff and clients which shall include but is not limited to:

(a) hand washing rules;

(b) not permitting staff to work when sick;

(c) sanitizing rooms utilized by sick staff or clients; and

(d) procedures for limiting the exposure of healthy individuals to sick individuals.

 

R501-2-14. Emergency Plans.

(1) The program shall have a written emergency response plan describing how staff shall respond in an emergency, including but not limited to severe weather, a fire, natural disaster, prolonged disruption of utility services, medical emergency, a client who may be missing, or significant criminal activity, to include:

(a) designation of authority and staff assignments;

(b) plan for evacuation, including but not limited to evacuation of persons who are non-ambulatory and persons with disabilities;

(i) all staff and clients shall evacuate from a building within two minutes after an alarm; or

(ii) all staff and clients in a program that is under exclusive contract with DSPD and provides services only to DSPD clients shall evacuate from a building in accordance with an emergency plan that has been approved in writing by an Office of Licensing Life Safety Inspector;

(c) transportation and relocation of staff and clients, including but not limited to transportation and relocation of persons with disabilities;

(d) location, supervision and care of clients after evacuation or relocation, including but not limited to care of persons with disabilities;

(e) notification of each client's guardian; and

(f) reporting significant criminal activity or medical emergencies to local law enforcement, emergency first responders, and the Office of Licensing.

(2) The program shall comply with its approved emergency response plan.

(3) The program shall educate staff and clients on how to respond to emergencies.

(a) The program shall conduct quarterly emergency response drills, including fire drills.

(b) The program director shall maintain a detailed written report for the Office of Licensing that assesses staff and client compliance with the program's written emergency response plan.

(4) The program shall comply with the written safety requirements of the local fire department, including but not limited to requirements regarding emergency exits.

 

R501-2-15. Safety.

(1)(a) The program shall provide staff and clients with emergency access to an operable telephone at all times.

(b) Local emergency telephone numbers, including fire, police, poison control, emergency medical personnel, and other local emergency numbers, shall be visibly posted by each telephone.

(c) On-call staff telephone numbers shall be immediately available to on-duty staff.

(2) The program shall have a first-aid kit readily accessible within 100 feet of all on-duty staff.

(a) The contents of each first-aid kit shall be as recommended by a nationally recognized program, such as the American Red Cross, or approved in writing by a medical practitioner.

(b) The contents of each first-aid kit shall be inventoried and restocked within one week after each use, and no less than monthly.

(c) First aid kits that include any medication shall be locked.

(3) The program shall have at least one first-aid kit, one operational carbon monoxide detecting device, one operational smoke detector, and one fully charged fire extinguisher on each level of each building.

(4) A program shall place all hazardous chemicals and materials, including but not limited to poisonous substances, explosive or flammable substances, and cleaning supplies, in locked storage when not in active use.

(a) Hazardous chemicals and materials shall be stored in:

(i) the manufacturer's original packaging together with the manufacturer's directions and warnings; or

(ii) a container that complies with the manufacturer's directions and warnings and is clearly labeled with the contents, manufacturer's directions and warnings.

(b) Flammable substances, including but not limited to gasoline, kerosene, and propane, shall be locked in a ventilated storage area or OSHA approved storage cabinet separate from office and living areas.

(c) Except as provided by Subsections R501-2-15(4)(c)(i) through (iii), a client shall have no access to any hazardous chemicals or materials, including but not limited to poisonous substances, explosive or flammable substances, and cleaning supplies, unless the client is directly supervised by staff.

(i) A program may assess a client and provide unsupervised access to a hazardous chemical or material only after the client demonstrates the ability to use the hazardous chemical or material safely.

(ii) A client's individual assessment shall provide a detailed description of the assessment and shall be signed and dated by the direct care staff performing the assessment.

(iii) A client's assessment shall be filed in the client's individual file.

(5) A program that permits any person to smoke or use tobacco products shall:

(a) have and comply with a smoking and tobacco products policy;

(b) prohibit smoking and the use of tobacco products by or in the presence of a child;

(c) prohibit smoking and the use of tobacco products in any enclosed area; and

(d) comply with the Utah Clean Air Act.

(6) A program that provides food for its clients shall comply with Rule 70-530 Food Protection.

(7) A program that provides food for its clients shall not serve and shall promptly dispose of food:

(a) after the expiration date on the food package;

(b) after the "best used by" date on the food package;

(c) two weeks after the "sell by" date on the food package;

(d) infested with insects or vermin;

(e) that looks or smells spoiled or moldy; or

(f) in a can that has any damage to its seams, has rust, or is bulging.

(8) A program shall have policies and procedures that describe which animals are permitted or restricted on-site.

(a) Animals that are owned, sheltered or fed by the program, or whose freedom to leave the program site is restricted, shall be free from disease and cared for in a clean, safe, and humane manner.

(b) A program shall maintain a file documenting the health of each animal on site. The file shall include written verification of each animal's current vaccinations in accordance with the law and veterinary recommendations, health care, health history, and any incidents involving aggression by the animal.

(c) A program shall provide and document staff training and client training regarding the risks, proper feeding, cleaning shelter and handling of each individual animal prior to permitting any contact with that animal.

(d) A program shall immediately isolate an animal that bites or attacks any person and causes an injury, and shall report an incident to local animal control authorities within 24 hours.

 

R501-2-16. Weapons.

(1) Dangerous weapons shall be inaccessible to clients, except as specifically authorized in the program's written policy and procedures manual.

(a) The program shall take into consideration common household items that may be used as a weapon.

(b) A program's manual shall describe which weaponsare permitted and which are prohibited on site, and shall also describe how weapons shall be stored, and the circumstances under which they may be accessible to clients.

(i) The determination of permitted and prohibited weapons shall be made in accordance with the age and behavioral characteristics of the client population served.

 

R501-2-17. Transportation.

The program shall have a written policy and procedures regarding transporting clients, which shall include:

(a) each occupant of any vehicle transporting a client shall have and use a properly functioning seat belt;

(b) a client shall not be transported in the bed of any vehicle; and

(c) a client shall not be permitted to transport another client unless the client who is driving is the parent or spouse of the client being transported.

(2) An adult client in an adult treatment program may transport another adult client in the program if:

(a) the program has and complies with a written policy and procedures that address safety factors, including but not limited to its clients' presenting problems, risk to other clients, staff and the community, age, maturity, and behavior;

(b) the client driver first submits a current driver license and annual Department of Public Safety driving record to the program, to be retained in the client file, which indicate the client's license is currently valid; and

(c) the passenger voluntarily consents in writing to being transported by a client driver.

(3) A program's minimum staff to client ratios, as described in that program's categorical rules, shall be maintained while transporting clients;

(a) staff who are off-site providing transportation services shall not be counted when determining program compliance with on-site staff to client ratios; and

(b) staff shall not transport any client on a motorcycle or farm machinery, as those terms are defined in Title 53.

(4)(a) The program shall maintain on-site a copy of the current registration and insurance verification records for each vehicle, including a privately owned vehicle, it uses to transport a client.

(b) Insurance records for a privately owned vehicle used to transport a client shall document that the policy includes coverage for transportation of clients.

(5) A vehicle used to transport a client shall be maintained in a safe condition.

(6) Each vehicle used to transport a client shall visibly post emergency information in the vehicle, or maintain emergency information together with registration and insurance documents in the vehicle. Emergency information shall include the name, address and phone number of the program and an emergency telephone number for a program management person.

(7) Staff shall not transport a client without first submitting a current valid driver license to the program for the type of vehicle driven.

(8)(a) Each vehicle used to transport a client shall be equipped with a first-aid kit as recommended by a nationally recognized program, such as the American Red Cross.

(b) The contents of each first aid kit shall be inventoried and restocked within one week after each use, and no less than monthly.

 

R501-2-18. Categorical Rules.

A human services program shall not provide child placing adoption services without first obtaining a license and complying with Child Placing Adoption Agencies Rule R501-7.

A human services program shall not provide outdoor youth program services without first obtaining a license and complying with Outdoor Youth Programs Rule R501-8.

A human services program shall not provide social detoxification services without first obtaining a license and complying with Social Detoxification Rule R501-11.

(a) A human services program shall not provide child foster home services without first obtaining a license and complying with Child Foster Care Rule R501-12.

(b) A program licensee authorized by the Office of Licensing to certify foster or proctor care homes shall:

(i) approve applicants only after first verifying and documenting the applicant's compliance with the Child Foster Care Rule R501-12;

(ii) recruit, train, and supervise foster and proctor parents in accordance with all requirements of Rule R501-12;

(iii) maintain written records of each annual home study evaluation, compliance with Rule R501-12, and completion of training requirements;

(iv) have a written procedure, including an appeal process, to suspend, revoke or deny a foster home or proctor home certification;

(v) have a written agreement with the foster or proctor parents which includes the expectations and responsibilities of the program, staff, foster or proctor parents, the services to be provided, the financial arrangements for children placed in the home, the authority foster parents can exercise on children placed in the home, actions which require staff authorization;

(vi) plan, with participation of the child's guardian, for care and services to meet the child's individual needs;

(vii) obtain, coordinate and supervise any needed medical, remedial, or other specialized services or resources with the ongoing participation of the foster or proctor parents;

(viii) provide quarterly supervision of foster and proctor parents to monitor the quality of the care they provide;

(ix) not grant a variance to Rule R501-12 without the prior, written consent of the Director of the Office of Licensing; and

(x) not authorize a variance to any law or regulation.

A human services program shall not provide adult day care services without first obtaining a license and complying with Adult Day Care Rule R501-13.

A human services program shall not provide therapeutic school services without first obtaining a license and complying with Therapeutic Schools Rule R501-15.

A human services program shall not provide intermediate secure treatment services without first obtaining a license and complying with Intermediate Secure Treatment Programs for Minors Rule R501-16.

A human services program shall not provide adult foster home services without first obtaining a license and complying with Adult Foster Care Rule R501-17.

A human services program shall not provide residential treatment services without first obtaining a license and complying with Residential Treatment Rule R501-19.

(10) A human services program shall not provide day treatment services without first obtaining a license and complying with Day Treatment Rule R501-20.

(11) A human services program shall not provide outpatient treatment services without first obtaining a license and complying with Outpatient Treatment Rule R501-21.

(12) A human services program shall not provide residential support services without first obtaining a license and complying with Residential Support Rule R501-22.

(13) A human services program shall not provide more than one category of services requiring a categorical program license without first:

(a) obtaining a license for each category of services offered; and

(b) complying with the most restrictive categorical rules in any facilities, activities, or services shared by the programs.

 

R501-2-19. Compliance.

Any licensee that is in operation on the effective date of this rule shall be given 90 days after the effective date to achieve compliance with this rule.

 

KEY: licensing, human services

Date of Enactment or Last Substantive Amendment: [March 17, 2004]2007

Notice of Continuation: November 25, 2002

Authorizing, and Implemented or Interpreted Law: 62A-2-101 et seq.